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You look at the person standing next to you and you cannot see their face. You want to put the key in the lock and you can’t get to it. You are trying to dial a phone number, but the picture is blurry. Zuzanna Opolska, a journalist from MedTvoiLokony, talks with the ophthalmologist prof. Andrzej Grzybowski.
- Age-related macular degeneration (AMD) is a chronic, progressive disease of the central part of the retina (or the macula), resulting from tissue aging and the development of atherosclerotic lesions in the capillaries of the choroid
- The main reason for the increase in AMD incidence is the almost twofold increase in the average life expectancy of societies in Western countries in the last century.
- Currently available methods of treatment (injections into the eyeball with anti-VEGF preparations) allow to stop the disease in most patients
Zuzanna Opolska, MedTvoiLokony: Professor, at what age should we start to be afraid of AMD?
Prof. Andrzej Grzybowski, ophthalmologist: Age-related Macular Degeneration (AMD), or age-related macular degeneration, affects the 60 plus population. The most vulnerable are women over 75 years of age, who experience initial changes twice as often as men of the same age and seven times more likely to have advanced changes.
Age-related macular degeneration is called the “blindness epidemic”, why?
In connection with the extension of the life span, and thus the so-called As societies age, the number of AMD patients is growing rapidly. In Poland, about 1,5 million people are affected by macular degeneration, and forecasts indicate that by 2020 the number of people suffering from this disease may increase to 2 million! AMD is a chronic disease, which means that from the moment of diagnosis it will be with us for the rest of our lives.
Age is a major risk factor, but what else influences the development of AMD?
As for prophylaxis, the matter is quite difficult. Some risk factors, such as age and genetics, are beyond our control, while others are. Smoking is the most important risk factor in this group. It has been proven that people who smoke get sick three to four times more often than non-smokers. It can be said that today, not smoking is the most important preventive message. It is also known that cardiovascular diseases, hypertension, obesity, and atherosclerosis may increase the risk of AMD.
What symptoms should worry us?
Primarily, age-related macular degeneration causes a decline in visual acuity – that is, a deterioration in both near and far vision that cannot be corrected with glasses. We must remember that in old age – over 50, all people lose the ability to accommodate – that is, see up close, and therefore need glasses. With AMD, despite the use of the best distance or near correction, the quality of vision does not improve. Other symptoms include poorer color perception, wavy or distorted image, as well as the presence of a more or less transparent stain – the so-called scotoma in the center of the field of view.
How is the disease going?
With AMD, the first changes are very discreet and may not affect the quality of our vision. However, they will be visible at the back of the eye, where the deposits of metabolic products of the retina, the so-called druzy. The disease may progress differently depending on whether it becomes dry or wet (also wet, neovascular).
Which of them is more dangerous?
The exudative form is usually severe, and the significant deterioration in vision can occur rapidly, even over the course of several days. It happens as a result of the formation of abnormal blood vessels in the area of the macula and the formation of the so-called subretinal membrane, which leads to overflows and hemorrhages. As a result of progressive lesions, the patient gradually loses the ability to function independently – central vision is impaired, which is necessary to perform basic everyday activities, such as: reading, writing, recognizing the face or reading road signs. In the wet form of AMD, if left untreated, the vision may be partially or almost completely lost.
What tests can detect AMD?
Diagnostics include OCT (optical coherence tomography), fundus examination and fluorescein angiography. These tests provide complementary information and allow 99,9% of AMD to be diagnosed. In addition, the ophthalmologist in the ophthalmological examination itself has the opportunity to assess the retina and it may already suggest some changes to him. It is important for people suspected of AMD or already diagnosed with AMD to self-monitor their eyesight by, for example, performing the Amsler Test. If we notice that we can see much worse in one eye, it is the basis for a referral to an ophthalmologist.
What is the treatment for AMD?
When it comes to the dry form of AMD, the only currently available treatment method, and in principle inhibiting the progression of the disease, is the use of a special set of vitamins and microelements. The AREDS (Age-Related Eye Disease Study) study conducted in 2001 showed that daily supplementation with antioxidant vitamins (C, E and beta-carotene) and minerals (zinc, copper) reduces the risk of developing advanced AMD within 5 years 25%. In another AREDS 2 study conducted five years later, lutein, zeaxanthin, docosahexaenoic acid, and eicosapentaenoic acid were added to the AREDS formulation. It turned out that the addition of lutein and zeaxanthin to the original supplement did not affect the progression of advanced AMD compared to using only the AREDS formula. However, removal of beta-carotene is beneficial because it increases the risk of lung cancer in smokers. Importantly, both studies confirmed that the use of the formula has no effect on the condition of people without or with very early symptoms of AMD. A balanced diet is suitable for them.
And the treatment of the exudative form?
Currently, the gold standard is Vascular Endothelial Growth Factor (VEGF) blocking agents administered by intravitreal injection into the eye. It is only symptomatic treatment, which, by closing or limiting the leak from pathological, newly formed choroidal vessels, slows down the process of central retinal degeneration, and thus the loss of vision by the patient. Unfortunately, the injections must be repeated at regular intervals of several months, practically throughout the patient’s life. Treatment should be started as soon as possible and realistically within four weeks of diagnosis. A delay of more than 28 days is statistically associated with the deterioration of visual acuity and may cause disability.
Anti-VEGF therapy is also a treatment option for diabetic retinopathy …
Yes, but in the wet form of AMD, anti-VEGF therapy is reimbursed. This means that every patient who meets the eligibility criteria * for the drug program has free, systematic access to therapy. The list of treatment facilities can be found on the National Health Fund website (http://kolejki.nfz.gov.pl/).
What if I have an exudative form, but do not meet the criteria? Do I need to be treated privately?
Private treatment is very expensive and prices vary. An alternative is Bevacizumab, a preparation that is administered off-label. In the field of wet AMD therapy, its effectiveness and safety have been confirmed by CATT and IVAN studies, published in the most prestigious journal in the world, “The New England Journal of Medicine”. Patients who have been disqualified from the drug program have the right to be treated according to group B 98, which accounts for the treatment of AMD with Bevacizumab.
The patient has the right to expect that after reporting to the selected hospital, his treatment will be started there. Otherwise, they can contact our Foundation (Fundacja Opulistyka 21, [email protected]) and we will try to intervene or find another center. Likewise with diabetic macular edema. Currently, the patient can be treated in public ophthalmic wards free of charge according to group B 98. Refusing treatment to a patient is against the law and should be reported to the National Health Fund, Patient Ombudsman or non-governmental organizations such as the Ophthalmology Foundation 21.
Does anti-VEG therapy have side effects?
Many studies, including IVAN and CATT, have found that administering anti-VEGF drugs topically to the eye is associated with a certain risk of heart attack, particularly stroke. Therefore, it is very important that patients with a history of cardiovascular disease inform their ophthalmologist about it.
AMD, like cataracts, affects the 60 plus population. What if i have AMD and cataracts? Is surgery appropriate for me?
Yes. Let us not forget that lens opacities may prevent the diagnosis and treatment of retinal diseases due to the inability to assess the fundus. Previous studies have shown that cataract surgery is not associated with an increased risk of transition from dry AMD to wet form.
And can cataract surgery deteriorate eyesight in patients with wet AMD?
In this case, the research results are inconclusive. It is now believed that patients with the wet form of AMD should be treated with injections. Ideally, treatment should be for at least six months.
According to a study by TNS commissioned by the AMD Association, only 30 percent. Poles have heard about AMD …
For patients with AMD, but not only the Foundation for the Development of Ophthalmology “Ophthalmology 21” implements the project “I know about AMD”, which aims to provide information about the disease: its symptoms, types and factors increasing the risk of disease, diagnostic tests, methods and costs of treatment and the institutions involved in it.
Prof. extra dr hab. med. Andrzej Grzybowski – Head of the Department of Ophthalmology at the University of Warmia and Mazury and President of the Foundation for the Development of Ophthalmology “Ophthalmology 21” (http://okulistyka21.pl/). Laureate of prestigious domestic and foreign scientific awards. In 2017, in recognition of his scientific activities, he received the Achievement Award from the American Academy of Ophthalmology, and the Achievement Award from the Asia-Pacific Ophthalmology Academy. Member of many scientific societies, including the European Society for the Examination of the Eyesight (EVER), the European Society of Cataract and Refractive Surgery (ESCRS), the European Academy of Ophthalmology, the American Academy of Ophthalmology (AAO), board member of the European Retinology Society (Euretina). Author of over 350 scientific articles in peer-reviewed international scientific journals. Co-author of the books “OCT in Central Nervous System Diseases. The Eye as a Window to the Brain ”and“ Endophthalmitis in Clinical Practice ”.
* Presence of active (primary or secondary), classical, latent, or mixed choroidal neovascularization (CNV), accounting for over 50% of changes in the course of AMD, confirmed by OCT (optical coherence tomography) and fluorescein angiography, age over 45 years of age, size of the change less than 12 DA (12 surfaces of the optic disc), visual acuity in the treated eye 0,2-0,8 determined according to the Snellen table, the patient’s consent to perform intravitreal injections, no dominant geographic atrophy, no dominant hemorrhage. The selection criteria must be met cumulatively.